Putting Care Before Cost in Health System

IN Bill Clinton, the American people have chosen a president who will work with the Congress toward real reform of the health-care system. All major proposals for change, from insurance market reform to managed competition to pay-or-play to the single-payer model, promote two common goals - to make affordable health coverage available to the whole population and to control the costs of the health-care system. Focusing on just one of these goals is not enough. We will not achieve universal access without cost control, and we cannot contain the cost of the system unless we make affordable care available to everyone.

Redirection of national health-care policies must include strong emphasis on the education and reeducation of health-care professionals. If the way these professionals are trained is not changed, neither the federal government nor any other American institution will achieve control of health-care costs. The kind of care health professionals provide, how they provide it, how they interact with others, how they define quality, and how efficiently they work will do as much as any financing system to determi ne whether or not the system of the future truly serves the needs of the public.

Most of the increase in health-care costs is the result of growing emphasis on high-cost, high-tech, procedure-oriented specialty care. That emphasis begins in medical school, where young men and women learn the skills and values they will carry into the health-care system. Their skills and values typically are built around the hospitals that treat most difficult cases, the research agendas of medical faculty, and a national culture that rewards specialization and downgrades primary and preventive care. We continue to rely on specialists to overcome the failures of a system that too often provides too little preventive care, too late.

As the health-care system comes under increasing pressure to expand access, control costs, and maintain quality, primary care will be the key to viability. In most industrialized nations, at least half the physicians are generalists who provide primary care. In the United States, this figure is less than one-third. Worse, the medical students who will become tomorrow's physicians are turning away from primary care. Twenty-three percent of American medical graduates chose primary care residencies in 1989,

but only 14 percent chose primary care this year. We have an oversupply of specialists, a scarcity of primary care physicians, and a soaring health-care bill to show for it.

The nation's medical schools must lead the way in shifting the balance to primary-care fields like family practice, general internal medicine, and general pediatrics. In addition to a revised generalist-specialist mix in medicine, the emerging system will require enhanced skills of collaboration, effective communication and teamwork, and new roles for nurse practitioners, physicians' assistants, and other allied health professionals whose training allows them to replace physicians in many functions, at l ower cost.

Change will not come easily in the health professional schools. Many of their leaders entered medicine in times of ever-increasing resources, acquiring a "growth" mentality that will not be reversed readily. In addition, medical schools and teaching hospitals rely on insurers and patients for almost half of their revenues. Much of the care they deliver consists of costly, intensive, specialty care, thus creating a strong financial stake in encouraging specialization. Finally, the tremendous cost of medic al education is driving physicians to the more lucrative specialties, as the average debt for medical school graduates has grown to $56,000. Primary care physicians earn less than half the average income of most specialists, a distinct disincentive for young doctors burdened with heavy educational debts.

Some initiatives are under way to assist health professions schools in their efforts to change. The Pew Health Professions Commission has developed a set of "competencies" needed by all health-care workers in all professions, emphasizing primary-care skills. The Robert Wood Johnson Foundation is funding demonstration projects to encourage medical schools to adjust the generalist-specialist mix. Congress has updated federal health professions education programs to increase focus on primary care and has in creased funding for the National Health Service Corps.

Much of the coming discussion on health-care reform will center around changes in financing. But to make the system truly serve the American people we also must reform the education system that trains health professionals. Surely, their mission must be to serve the people, not the professions themselves.